Ok, I admit that I use APS purely for my own convenience rather than its rebranded PTCPS (PT Classification and Payment System).
For a refresher on prior APS posts go HERE and HERE and if you really want to go back HERE.
On Aug 12th, we had another fun @karentlitzyNYC podcast of #sipswJerLarKar this one completely dedicated to APS and we were joined by Dr. Sharon Dunn, APTA President. Although it is fair to say we don’t necessarily agree much on APS, it does not diminish the professional and personal respect I have for Sharon. Her candidness and willingness to discuss were indeed refreshing and a great step of enhanced communication by APTA. Rather than rehash the entire episode, I want to repeat for the sake of emphasis and clarity some points that were made that I don’t think many had previously considered.
#1. While imperfect and in need of re-valuation, the current CPT does best represent the evidence with for example manual therapy and therapeutic exercise as higher valued than ultrasound or traction. This certainly hasn’t always been the case and us old timers out there remember those days. An argument can be made that if a PT were solely concerned about reimbursement, that the current system could “nudge” them to success by rewarding them for performing the best valued codes which also happen to be the most benefit to patients as well. The recent Mitchell Study actually reflects this with the treatment of LBP of more active care producing better clinical outcomes at a lower cost.
#2. The current CPT code system is substantially more intuitive and objective than a proposed severity/intensity model. Consider this illustration:
Scenario 1 Current AMA 9700 series codes:
A patient with 8 week old LBP receives by a PT 15 minutes of manual therapy and 30 minutes of one on one therapeutic exercise. Patient has ODI of 22, pain index of a 5, comorbidity of diabetes and obesity. Which CPT code(s) should be utilized for billing purposes?
A. Manual Therapy
B. Therapeutic Exercise
C. Manual therapy and Therapeutic Exercise
D. Group therapy and Manual therapy
E. gait training and short wave diathermy
Scenario 2 using the APS system being endorsed by APTA but might be on pause but still appears to be their main agenda:
A patient with 8 week old LBP receives by a PT 15 minutes of manual therapy and 30 minutes of one on one therapeutic exercise. Patient has ODI of 22, pain index of a 5, comorbidity of diabetes and obesity. Which CPT code(s) should be utilized for billing purposes?
A. Low intensity/low severity
B. Low intensity/moderate severity
C. Moderate intensity/moderate severity
D. High Intensity, Moderate Severity
E. High Intensity/High Severity
F. Quit, you’re giving me a headache
Does anybody in their right mind believe that with enough training that there would be better reliability and consistency in the answers of Scenario 2 vs. 1?
Dr. Dunn made a very valid point in the podcast-that CPT coding for PT’s statistically is all over the map (or words to that effect). The reason has nothing to do with the codes and everything to do with the asinine rules that surround them-8 minute rule, group therapy, always changing edits, modifier interpretation, etc. etc. This post, originally from 2008 illustrates that point exactly. A point I harped on with agreement by all was real significance to PT’s would be made if we could just eradicate some of the superimposed rules, technical requirements, documentation requirements, plans of care, PQRS, modifiers, exceptions process, which would allow the PT to spend more time with the patient and have much improvement in coding consistency.
#3. Any coding system change should have to be examined for its direct and indirect (unintended consequences) effects as well as its reliability and validity. We only know that the unpublished GAGE study doesn’t meet that criteria set. Aparently, it showed better reliability at the extremes for the 5 categories. There is a mistaken belief that since it was more reliable at the extremes that if they simply reduced APS to 3 categories than it would be the most reliable system and this is from a profession that is wanting to be steeped in evidence. Using that logic, why isn’t the APS one code? Of more criticality, is the extreme documentation burden that it would put on PT and PTA’s. We know from AMA studies that MD’s are spending north of 20% on documentation, non-patient time. Our internal studies show it more in the 25% range and with medicare over 30% given their additional requirements. An intensity/severity model would certainly require the PT to spend more methodical time classifying through writing or be concerned for the risk of recovery audits. As Jeff Hathaway, said in the podcast, PT’s admit they are more worried about making a documentation mistake than they are about doing what’s right for the patient. Any PT want to spend more time documenting?
and lastly,
#4. APS moves the profession backward, downstream, and away from where value is being demonstrated. As PT’s we want to be rewarded for value-outcomes with lower cost. There have been significant studies in the past 2 years showing the value of PT in direct access of acute musculoskeletal injuries and how that creates significant and unquestionable savings in downstream imaging, pharma, and surgery. Well, under APS, your reimbursement would be even lower than it is now! You would have the perverse incentive to wait till the patient becomes more severe and chronic so that you can get paid more!
Unquestionably, the entire profession is in agreement that a more comprehensive coding solution should be created that reflects the value of therapy services. However, can’t we hit the reset button and start over while CMS is giving us broad flexibility in doing so?
Thoughts?
@physicaltherapy
Views expressed in this post are mine and not reflective necessarily of any organization.
